medical technology company executive found new ways to deliver care -- health care in

the health care industry or a discussion hosted by pepperdine university. this is one hour and 20 minutes. please welcome to the stage john figueroa cochair of the health care symposium committee and ceo of genoa health care. [applause] >> what an incredible morning. the insight that doctoring emanuel regarded the results in the future the affordable parents as well as integrated care and power industries moving to a value-based system was fascinating. equally as intriguing was the description of our complex and ever-changing health care system by our esteemed panel of doctors and health care administrator's. i trust that their years of practical experience and i trust

that they have certainly confirmed the complexity of our health care system and the speed in which it's changing in america. i'm going to take a little bit of a different view on this some of his comments consistent with some of the complexity issues of the day, consistent with things that we need to do to change the system to make it better but a slight difference in quality perspective. today as the indicated health care represents approximately 18% of our countries gdp. i think it is safe to say that the health care industry is perhaps the most important part of our economy and growing fast. that was something that was confirmed with all speakers today. because of this over the past decade we have been building health care around the aaa

concept that came 10 years ago and what we need to do as a society within health care to increase and improve health care , to increase quality, to decrease cost and to improve the visit and the accessibility for our country. what we learned this morning is that we have made tremendous progress with this initiative and the next massive shift will continue to be towards body-based health care. getting paid for products and services on the basis of how well they achieve the aaa. after reflecting on what we have heard today i think you can come away with a few impressions. one is that in this country we have massive issues with both cost and accessibility throughout health care but we don't have those major issues as it relates to quality of health care in america and that's a

little area where i take exception to some of the things that have been said not only this morning but when you watch the news or when you talk about health care and a general setting we sometimes lose the focus of the exceptional quality of health care that we have in our country and it has remained constant from a high-quality perspective. sometimes that gets politicized and not talked about at all. the fact is that america has the highest quality health care in the world and certainly the best technology and impact positive outcomes. we heard a lot of talk during the election campaign of our systems and comparing our systems to sweden. we even heard our system compared to morocco today. no disrespect to sweden or barack obama mike 26 years in the industry i've never heard a person say i would like to get a

procedure done in morocco. [laughter] >> never. granted a lot of these countries that we were talking about through the election process has health care coverage for all citizens and that's great but the other thing we don't talk about is that's not free and for those of you who studied business at our great school of business at pepperdine or anywhere else used it learned day one and economics that everything has a cost. in fact my grandmother who had a ninth grade education always said nothing is free. our great system has come at a cost no doubt and it's up to us to again continue to drive quality at a lower cost and make it accessible to all. we have always been a caring nation and the notion that we will allow people to perish because they did not have insurance is frankly nonsense

and you heard cedars-sinai in mayo clinic talk about the fact that a number of their procedures and care is given and no cost at all to the patient. in fact when the affordable care act they get paid pennies on the dollar for a number of procedures that they do every day. most of our hospitals and care centers are not-for-profit. mental health for example 95% of community mental health centers, and these places take care of 90% of our country severely mentally ill are not-for-profit. there charity organizations that would never turn away a patient that has no insurance and a lot of people who do those services are here today and i want to thank you for what you do for our patients and our health care system. granted sometimes you may not get the highest -ranked hospital in the country to take care of you if you have insurance but there's always a place for care

in america. this is true before the aca and it's true today. i suspect it will be true in a new health care program announced in d.c.. however it's also true and very possible that a major procedure could bankrupt you and our system or that an uninsured person will be taken enduring the crisis but can't afford her band of care. again this happen before the affordable care act and it still happens today. we must continue to strive towards an industry and we are. another fallacy is that they large pharmaceutical companies are the primary reason for instability and health care costs. total pharmaceutical costs in health care represents about 15% of the total cost. even if drug inflation rates went to 0% it would not change the overall escalating cost of care.

today 85% of prescription drugs are generic and an average cost of $10 per month per 30-day prescription. because our health care system operates in silos there can be a short-sighted emphasis on reducing costs in each silo and i'm not advocating that there is nothing that can be done to the pharmaceutical industry and there are plenty of examples where costs are way too high and we need to as an industry address those issues but we can't take any of health care one silo at a time. let me give you an example of what happens when you concentrate specifically on pharmaceutical spending. in the spotlight is focused -- if the spotlight is focused on pharmaceutical spending and increases seen as problematic. if spending on pharmaceuticals need to increase to achieve

overall reduction in the total cost of care. for example and patience to stay their meds you will see an increase in drugs. an insurance company if they see somebody experiencing 96% adherence rate from 20% they are going to spend more on pharmaceuticals. what you have to look at is the total cost of care. it has to reduce the higher amenable cost. recently we did a study that determined if in fact you are putting pharmacies inside these community mental health centers and you are taking away the ability for them to leave the center and then go get their prescription severely mentally ill patients will fill their prescription at least 20% of the time. if there's a pharmacy and vetted and integrated in the community mental health center sibile -- severely mentally health patients take their meds 96% of the time.

that's what the journal of managed care said. a 40% reduction in hospital stay 18% reduction in your visits amounted to over 400 million dollars in savings on the basis of 500,000 patients. i don't understand the word trillion like any of us but i do understand $400 billion the impact to this patient population. so that's what i want to leave you with. the fact that let's not look at silos. let's continue to work together to look for total cost of care and let's make sure as a society and the health care industry would continue to reduce costs increase access and improve health. so with that we are going to talk a little bit about

technology and the technology impact that it's having on quality of care in our system. today's panel is pretty exciting. we have heard a lot of talk about telemedicine and earlier conversations today and last year's symposium and entire symposium on data technology and the impact it's having. today we have three great panelists and we also have a moderator that comes to us as one of our panelists last year kathleen grave who has a history of making sure innovation is impactful. she is one of the designers and executives of watson with pbm and is currently now part of the watson program with the weather channel revolutionizing what we do with technology. please welcome kathleen grave. [applause]

>> hello and thank you. what a great morning it's been so freer -- so far. i'm looking forward to having this conversation. first i wanted to see you too telemedicine. what do we need bike along the the -- what do we mean by telemedicine and telehealth? telehealth is a general term that encompasses all inclusive health care provided by a means of telecommunications and information technology. it can include preventive promoter than curative care delivery. telemedicine is more specific to the gauge meant of the interaction between the provider and the patient and the medical services that are provided. it is patient clinical care delivery remote services. can be critical care. can be emergency care and it can include technical and diagnoses remotely and often for critical condition. between the doctor and the

physician and the patient telemedicine provides access long-distance and remotely to experts with experience that otherwise would not be available in remote areas of the world or remote provinces or rural areas of united states. american telemedicine association likes to give us a very early example of telemedicine and that is the medical care provided in the monitoring of the astronauts and the early-stage program that continues today. it was also used in military or remote deployments to keep the troops safe. telemedicine provides three areas of patient care focused on instrumented interconnected and intelligent s in transmission access for radiology imaging and this gives us the inside and provides insights that are needed to provide the information for the

details of the data. also remote monitoring of the chronic care or special circumstances so for example congested heart earlier for example one needs to get the regular vitals of the hydration and the vitals of the patient. clinical consultation is the third in lieu of face-to-face interaction for convenience and to allow for it to happen more often on a regular basis. the use of electronic information and telecommunication technologies to support is now common and it's coming to provide long-distance critical care health education, public health and health of frustration to technologies include videoconferencing and the internet is a very common practice now. includes forward imaging streaming media and terrestrial and wireless communication. there's no end of the communication happening around this area of health care and we

are going to see it counts many folds in the next few years as well. data and sites offer the fingertips of the provider of the caregivers to transform the patient experience. never before have we had as much information at their fingertips to take care of the information being shared between payer provider and patient. with the transformations include telemedicine and mobile health solutions and patient care management we have the opportunity to increase access to improved high-performance health care systems improving clinical decision-making at point of care enabling access to all levels of special care while reducing cost and resources in minimizing the patient ensured. we have the opportunity to extend patient care beyond the office for convenience consultation promote access and as i said and rural areas. he can be focused on patient specific management or risk

management for population with common chronic care or need such as heart disease diabetes although depending on which care management program is created. access to previously to an accessible specialist is outside the metropolitan area so when providers graduate from college and would like to stay in the city they can provide remote access to patient and to provide support to those doctors and patients that are remote. it reduces travel for patients who might need frequent visits check-ups and monitoring for clinical situations. enabling flexible learning options for physicians consultation training care management programs bringing together a team of specialist to discuss a specific case management provide an opportunity for feedback and even bring in other nonclinical roles are experts you can contribute to that information based on the environmental cultural nature of the patient.

one common view of the trusted information means experts can now contribute from all facets of their expertise. it is now my privilege to bring on the stage iii panels who will share their experience and expertise as well as their perspective to answer some of our questions about the industry their specific as those models and application of telemedicine. our first panelist is mr. hill ferguson chief executive of doctors on the man with two decades of experience in global technology. hill has led companies from all stages of growth from being a founder to an executive to a high-growth company. he also holds a deep commitment to putting customers first by delivering the best possible products of value that resonates with doctor commitment to its leading industry clinical quality and best in class customer experience. before joining ferguson helped

transform paypal into a focused technology company and eventually serving as the company's chief roderick officer. prior to joining paypal in 2011 hill was vice president of marketing which pioneered technology that enable consumers to take weight and easily use a mobile phone. john built a vast network of two or 50 applications and operated in over 50 countries are building a merger network fund leading digital goods and on line and worked as general manager for he helped develop and market personal financial management software and consumer payment products used by leading financial institutions produce a senior product manager at yahoo! he helped create the award-winning yahoo! finance web site and developed a variety of payment services. he also cofounded loan back to

help consumers manage $1.7 billion in loan from friends and family. hill of the badger's degree and mba from vanderbilt and the san francisco bay area so let's welcome into the stage. [applause] our second panelist is samir malik. samir is the vice president come senior vice president general manager of genoa the quality of a health care company. he came into this role for an acquisition of this company a city-based telepsychiatry company which he founded and served as ceo. the company expands access to mental health care in rural america. samir's team is built the technology enabled services company from scratch treating 50,000 patients across the country and prior to that samir was the presence of signature health care and to health care service companies that he started and led.

these two endeavors have grown the past five years from two employees to over 150 employees while improving access to health care market and populations in need of mental health access. from 21,022,012 samir was the director planning at centerpoint hospital and 150 bed health system in st. louis missouri where he designed and built a new model for outpatient until health programs across three states. bredesen prehospital samir's were became as a business analyst for a focused and strategic and operational initiatives for large organizations both inside and outside of health care and while he served at the mckenzie hospital. samir received a bachelor of economics at the university of pennsylvania at bachelor of arts in neuroscience and a masters of business administration at wharton health care management and he doesn't sleep. what's -- let's welcome him to the stage. [applause]

our last panelist is mr. lou silverman. lou silverman is a 20 year track record as ceo of health care technology companies translating transformative benefits and innovative health care solutions in a successful clinical and commercial organization brings experience in building companies enabled high care quality drive intelligent growth and serve as catalysts for evolutionary industry change is at the very heart of its business. silverman is committed advanced care to working collaboratively with his hospital partners and their team to bring the promise and positive outcome of teleicu services to the patients and families we jointly serve. prior to joining advanced icu care silverman's deep experience with innovative help companies each among the early leaders and

pioneers in health care services market informed advanced icu focus. pursuing a strategy of building organizations designed to deliver sustained success advanced icu care and continue investing in clients staff and infrastructure to ensure continued innovation and ongoing set or leadership. during his tenure and to park companies they were both named to the form's magazine of 200 best small public companies for a total of 15 consecutive years. in addition to his leadership role silverman serves on the board of directors for a variety of health care-related companies both public and private. he earned his mba from harvard business school and his va in american studies from amherst college so let's welcome him to the stage as well. [applause]

i would like to welcome out to the stage and we'll get started with a little bit of a round of introductions and perspectives from each of our panelists. >> afternoon everyone. there are mobile apps web sites that can connect to two board-certified physicians in 49 states into the 50 guests in his arkansas passes some legislation here momentarily and basically started out in the consumer market in 2014 launching our first product as a catch pay solution for lack of access to urgent care. he grew really quickly and quickly started to work partnerships with large insurance companies like united health care as well as large self-insured employers who now offer the covered benefit as hard as -- part of their health

care design. this is fueled our growth and we have gotten into mental health. we built a team of psychologists and psychiatrists who work together with their primary care physicians to help provide a suite of health care solutions for consumers who were both speaking on the direct market as well as partner for health plan. we are really excited about the future of telemedicine. i think it's an incredibly exciting tailwind for everyone in this room. everyone plays of rolling can benefit from it. unlike my previous industry it's not really a winner-take-all marketplace. there is no application for providers, for players, for consumers and there are so many different point solutions out there focusing on specific cases that i think are driving innovation that's going to lead to brand-new designs for health

plans as well as changing the way consumers think about becoming consumers in this marketplace. i'm happy to be here and i look forward to the conversation. >> good afternoon everybody and thank you again for inviting us to share some of our experiences with you. general psychology is a country country -- company sick seers in the making primarily focused on gains we have seen from the cedars and mayo clinics leaders that we heard earlier today. our focus is on innovating for the mental health population. we are the nation's largest health patient telepsychiatry provider and what that means is we have a team of about 200 psychiatrists who work with us and we partnered them using a technology system that we we have built in-house so those physicians can treat patients who are otherwise not able to access psychiatric care. most often what we have found is that patients are seeking services at primary care clinics

community health clinics. a lot of the safety net care settings we have heard talked about earlier today but these care center some have access to psychiatry. our providers able to treat these patients using our platform. helped fit the patients -- 50,000 patients. one story i hope you can share over the course of this panel is the importance of getting the business model right. we have heard a lot of talk about innovation from john throughout the conference and innovation isn't as easy as having an idea but requires understanding the stakeholders, the patients, the payer system the other care managers involved in a patient's care so that you can build something that works for everybody. we spent six years trying to get that right and we don't have the perfect yet but we feel like we are well on our way to helping expand psychiatry and hopeful we

can share some of our lessons with you today. >> a company that is a classic tech enabled services company clinical services company. we operate on the 24-765 basis providing intensive care units around the country. we are in 24 states at this point in time north of 65 hospitals. we are in the process of celebrating a little bit of the company milestone which is we wired our 1000th -- and we see well north of 60,000 patients a year at this point in time. read the nation's largest icu. in terms of some of the themes we talked about so far today we are living through all of those. to samir's pointer business model is almost perfect but not

quite. we are getting there. our outcomes are very strong. some of the headlines we typically lead with our mortality rates reduced somewhere between 30 and 40% per icu with our involvement and became talk about good health care and people walking out of the hospital that weren't planning on doing that. it's a pretty good outcome. the length of stay reduces between 25 to 30% which has good individual and economic outcomes for all of the stakeholders in the process. we deliver our service through a number of care centers, now eight across three countries in six timezones. we have all of our physicians are board-certified and again we are always on 24-24-365 printer

workflow continues to be refined our acute awareness of the fact that we are dealing with multiple constituencies dealing with their own physicians who were hired as i mentioned the multiple cities bedside clinicians, patients, families, hospitals. we are not alone but we have inherited a very complex mix of business objectives and we are executing really will across all of those objectives. that's a quick summary of our company. thanks for having us. >> thank you very much. we know the telemedicine is growing. to rowing industry. it's currently a 20 billion-dollar market opportunity. and yet still only 1% of all businesses are happening in telemarketing in the country became curious when when you have a good idea and the need to move it into business model how did you get started quick if

each one of you could address that, that would be great. >> i can start. for us it came down to first understanding who are stakeholders were. we saw the patients who need services of course but we can't treat patients without physicians. because we chose to treat haitians at a clinic setting an institutional setting those clinics were the third stakeholder and then the payer in the ecosystem who's going to pay for the services and without considering the interest of all for stakeholders each of which is a leg to the stool and the stool to sustain without all of them the model would grow the right way so we think about patience and what are the services they need the most. how do we make sure the providers we have our high-quality to create the right engagement advocacy is it comes back to our physicians on a platform for treatment over the course of more than a year.

on the physicians side of things how do you compensate doctors in a way that makes it worthwhile? doctors r. r. ortiz stretched so thin and the supply nationwide is far short of where demand is. coming up with the right compensation model being able to reward doctors and give them the flexibility to work the hours they won the ships they want and in our case from where they want whether home or the clinic is also important that when it comes to the clinics in the payer's we have got to focus on reimbursement and i think that's often something left out of the conversation on innovation in health care. can you find a pathway to reimburse because without services you only have a limited shelf life for sustainability. grant funding pilot programs can only take you so far. our focus on medicaid population has driven by the cutie of the neat but also 40 medicaid programs to reimburse for telepsychiatry this country so

it allows us to expand at a pretty aggressive pace. >> from my gift i have been with with -- for a total of three years. my ah-hah moment came when i was try to figure out whether i was interested in interviewing for some of the ceo positions. having been through a number of innovative events and health care ecosystem including their early days of the emr revolution which some people think was a good thing and others not so much in the analysis for me was fairly simple and straightforward. i mentioned the things that were discoverable as part of my diligence. when you see a nascent service that is reducing mortality rates 30 to 40% length of stay significantly, doing that in a

way that has a good economic outcome on average, somewhere between two and six roi each year it became very easy for me to see that this has legs and he was an interesting opportunity. it was clear that it was the early days as it is for all of us and telemedicine, telehealth but you can't outrun those themes. try to keep things like this and simple. you will have great outcomes with a tangible roi in an area where lisa in our area dealing with a severe shortage of transit sense of this. being able to develop the those services and outcomes through positive roi. >> our story is pretty simple. all of us in this room manage their daily lives on their mobile phone. the check or bank account balances. we send funny, we order cars to take us to the airport and they

get here in two minutes. we order food to be delivered to our her home. why do we still been pick up the phone, call the doctor schedule an appointment for next week drive, park, wait, wait a little bit more, and then see a doctor for two minutes. why do we do that in this day and age? i was really the founding principle for doctor on demand to solve a problem. we started out with a simple service that could diagnose and treat 18 in the top reasons why people go into doctor office visits an urgent care when expavious a relatively simple things to diagnose and treat and from their we are able to find a core group of consumers who lack access or just value the convenience. our customer base is bifurcated among two different types of consumers. one folks who tend to live in more urban populated areas to live and guided die by their

mobile phone and do everything on their phone and they are looking for convenience is a natural way for them to get care and another segment which consist of people who live in areas where access to care is a real problem. one of the things i do everyday as i read our customer testimonials that people put out and it's a constant source of inspiration for me that's really to get feedback on how people perceive us and what problems we are solving with our solution that i can tell you many times i read thank you so much for your service. they used to have to drive 35 miles each way to see a doctor so we are really focused on accessing convenience is the two drivers. >> access is part of the model but we see it's just a reallocation of the same resources. the supply is short and the demand is high. have you seen that there may be a potential for new roles in the

model of delivering telemedicine or any suggestions on how to deal with the supply demand of resources? >> it's interesting we started out with contracting on an individual basis with short little blocks of a time where they could experiment and as we build sub volume we started hiring physicians full time. one of the reasons i think we have been successful is because we have tried to build a national practice of employed physicians across-the-board they care about our brand, that no patient experiences critical and more and more people come back and request appointments of those individual doctors. it's 30% of our business today are appointments selected from consumers who want to see a specific doctor whom they have had an interaction with paved the way we support that is doing

multistate licensure for these providers to demonstrate their ability to create good care. the license them in more states so they can have a larger pool of consumers to become patients with. that is really an interesting evolution of how people think about practicing medicine. we are able to think about typical primary care provider where i live in san francisco. they see patients every day and commute from you know several hours a way to get to a location and live in an expensive part of the country with really high cost and really stayed in everything else. folks in california know that. now we have people who live in little rock arkansas, that's a bad example, kansas with a much lower cost of living who can practice their craft and treat patients who live in san francisco.

it's interesting phenomenon of not just shifting arbitrage costs of living in delivery but also optimizing your time so we are able to allow physicians to work from home and see a number of patients and are in the same level of income but not have to be restricted to working in one part of the country. >> in terms of access in our case on the prior point we are really delivering expertise broccoli. we are sourcing it in a few markets in delivering that expertise to many markets. for perspective we have our own staff are on msl. we will license typically are physicians are licensed in north of 20 states. we do that ourselves.

we will credential them at many hospitals and that is so that we can solve that access problem and the shortage of staff that many many hospitals face. terms of supply one of the things that's interesting about arm model is that we contract directly with the hospital and so for physicians to join us they are for the first time in a long time able to focus exclusively on providing care to patients. they are not involved in any coding, billing, collection. they comment. they log into our system. they establish connectivity with the hospital they are assigned to and they are practicing medicine for the entirety of their shift and then they go home. so for people that are set up with chasing paperwork and bureaucracy and chasing after

payments and answering questions from management companies it's a pretty good gig. those are a couple of other pathways to consider. >> in addition to lou's point around taking the busy work off the doctors plate and lou's point about getting a license or more states to improve the liquidity of supplies there are a few other ways to telemedicine can help move the needle on supply. it can fill the hole gap but on the edges you can make a difference. one additional thing that we are seeing is that many of the providers who work with us use telemedicine in addition to regular full-time jobs. you are taking what be a 40 hour a week provider and turning them into a 45 or 50 hour week or fighter because they can do

mornings or evenings or weekends a second model is working such that our psychiatrist can support primary care providers to deliver more behavioral health care through the primary care channel. when a psychiatrist and primaries care office we are effectively helping that primary care provider manage health a little bit better. and yes -- unless you can find a way to find a physician to treat you are not going to solve the supply issue. >> we have all heard videoconferencing, cell phones, apps on your phone. what do you think might be the next disruption of technology to support telemedicine and have you seen it of the pipeline and is there any news on sensors or other technologies?

>> there is a wave of innovation happening on the hardware side where more and more we are able to grant power to smaller and cheaper devices. some of them are in your funds. for example the cameras on phones today are so powerful they can hold them up to your throat and doctors can have an image of your tonsils as good as in person, in some cases better because the light from the camera. i do think we will see in the next few years the cost coming down to low and enough levels where the average household can have a connected stethoscope, a blood pressure cuff all these devices that can take regular readings for vital signs in the them into a health record that your physician can read and monitor and start developing models of care that are preventative and corrective that

are possible with that data. that's an area where i can just almost bet my life that are going to happen within the most most -- the next decade. >> the choose is those that colleges are so far out right now that the applications can't really be distilled. i don't think any of us can be clairvoyant enough to know exactly how those are going to impact health care but we can assume something positive will come of it and innovators and entrepreneurs get their hands on new applications of technology however i would also suggest technology on its own as a panacea. there's so much work on the table right now in the care model's design predicted three of us can get our business models perfect we can have tremendous impact on the health care space without creating any meaningfully new technology. there is a lot of room to run

before we even start inking about things like artificial intelligence or things like that sphere from our perspective we are conscious of the fact that there might read some big innovations out there but we are practicing on a day-to-day basis relentless incrementalism. we are currently trying to add functionality to our proprietary software on a day-to-day basis that simplifies the work we are doing day-to-day with patients who need our help. we have a fairly active and robust development team that works in our shop and they work hand-in-hand in a nonbureaucratic way with our clinical staff where we have essentially the perfect lab for figuring out what needs to improve and we can test things quickly come innovate rapidly

and put things into production in a very rapid fashion. we are also reliant on third already technology. for perspective when we say we wire a room we have audio video connectivity with a high-resolution two-way camera in the room. from that location the camera can read the fine print at the patient's bedside. we have connectivity with the hospital information system and all the bedside equipment. we are working with just about, not just about, we are working with every impatient emr that exists in the country. we are working with them concurrently and seamlessly. we are continuing to evolve and improve our ability to assess all that data and efficiently process it.

but to be fair our perspective is on incremental improvement and we are leading the way in that area. maybe there'll be a big bang in our world but for now we are working on incremental stuff. >> now we will talk about cost. what is the cost outlook for all of this change happening pics is impacting payers, providers. to the patients see reduction in cost for the care? can you give us some insight as to that? >> in our model the two beneficiaries of cost savings are the consumer and the payer. typical visit costs for customers is half what they would pay if they went to a walgreens or cvs clinic and dirty to 40% what they would pay if they went to an urgent care clinic and it's much cheaper than going into an er. of course that's just for people who may have coverage or maybe they don't. the co-pay now with health plans

is going to cost you 100 bucks to see a doctor. that's a big area where we see cost savings. on the payer side which is why we are successful signing up several employers and health insurance companies is the same principle in motion. if i can get my employee to use doctor on demand instead of going into an urgent care clinic or an er as the payer i'm going to save anywhere from 100 to a thousand dollars. it's a very strong roi in the cost savings also on the employer side. a lot of our customers are employing workers that work shifts at restaurants and other places and if they can enable them to do a video visit on the job or in their car and it can prevent them from being off shift for three hours which is a big deal for them in continuing

operations in keeping an active workforce. >> i think cost savings occurs in two places. one is that the provider system level and the others on the payer side of things. like lou the contract directly with clinics and hospitals and because many of these hospitals we are working with are an underserved care settings there alternative to working with us is paying a significant market premium to attract physicians. a staffing body or paying premiums. our doctors are living where they want to live for treating patients in the care settings the weekend basically arbitrage that and get clinics access to positions as if they were located in a more desirable place. that is one and then on the payer side of things we are a

think the real impact, what we are seeing is the patient to see one of our decisions over telepsychiatry used 50% less inpatient utilization down 24 to 25%. you are really saving this patient downstream acute treatment because we are able to provide a layer of care earlier on in the development of their illness. there is cost savings on that side which vastly outweighs what we are doing on the provider supply-side. >> we were in discussions with a large national hospital system that will go unnamed in the session and we were trying to get in the door there and they made a deal with us. they said we are going to give you our worst possible. let's see what you can do and that deal we got back was we are going to work and you tell us

how we did because we don't want there to be any dispute about the numbers. they came back after a year and told us they couldn't even believe it. we generated a nine times return on our investment and a whole number of input as you might imagine with that one aspect to the other piece that i would point out here is one of the heartening things that we have seen particularly over the last nine to 12 months is increasingly our clients are featuring our relationship in their recruitment ads for clinical staff at the bedside. to the point that hill referenced some of the things that the privilege of reading i have seen nurses and physicians say i would not have joined the staff of hospital x or y if advanced icu care was not there. that's pretty powerful and it's also a hidden benefit may be of

an under calculated benefit in terms of helping reduce attrition and turnover at the bedside. so a couple of little antidotes they are. >> really important. we are seeing a triangulation of payer provider and the patient working for telemedicine. you have experienced and shared your approach to it and also now we are going to look a little bit at what do you offer in terms of regulation and policy changes? what needs to happen for that adoption to take place and not be breaking the rules anymore with some of the things that telemedicine has taken on? >> reimbursement is probably the biggest one. >> derrig natori free markets that exist today is somewhat tenable. we are all up here with functioning businesses because you can operate in this paradigm. the fact that all three of us

identified resources we are applying to licensed doctors in multiple states is probably an indicator and changes needed on the interstate licensure paradigm. we are spending a good deal out of her p&l. i'm sure you two are as well and to the extent that there can be some regulatory shift that allows providers to be able to treat patients across state lines with a bit more liquidity and cost application, that could be a big boost but i think that's secondary to reimbursement. reimbursement is key. >> i would concur. >> one thing that's interesting to me as it looks like telemedicine is integrating itself into the existing health care infrastructure that we no disruption the centralization etc.. do you see your ability to impact that change or do you see a need to impact any change?

>> i like to think that we are impacting the change by showing what is possible. as someone once said the only thing we need for good care is a doctor and the patient to come together through what we are trying to do is make that easy and simple for both parties and once every doctor's office or position practice as world last technology that enables them to follow up with their patients or place of video visit our job will be done. we will have shown the way there but i think it's going to take a longtime critic think there's a real need in the market to have solutions like ours out there for people who don't have numbers. there've population is never primary care physician, so it's going to be a long road to get there but i think the formulas are showing themselves and putting it out there that better

technology can solve problems for consumers, patients, doctors and payers. >> i would add to that that one of the things we have learned and where venue at gnostic in a way but i think there's a tendency to simplify a lot of what we do in the outside world and there's a tendency to think of all we do is we are recruiting clinicians and putting them in technologies and saying have at it. i think that one of the things that we have certainly learned and continue to practice his there is a whole client service ecosystem that's really important to keep the integrity of the clinical service working and whether that's from an i.t. perspective or customer service perspective having bad infrastructure and ecosystem while somewhat hidden from view

is really important in terms of allowing telemedicine to continue to march forward. you can have the best doctor on earth. you can have decent technology but if you get some of these elements wrong it's hard to recover from that. we have a foot in the future. now we have a foot in the present which is the obviousness of delivering an important tech oriented service backed by some very traditional customer service. >> two comments on telemedicine in the rain of disruption. first off disruption is the process of taking out the incumbents and replacing it with the new or the more innovative and i suggest the three of us here and others in the telemedicine space are

innovative so the description works as a tailwind for us. .. with deeper roots. >> is there any future that you

see where there would be a common platform or an approach that would make it easier for the patients working with each one of you to feel there is a common approach they would understand how they use that specifically if it is needed generationally for a different demographic? >> a lot of it is about getting the middle later back. >> pay with visa and mastercard or cash because you have this correct, that transaction layer is a little bit of secular to back at least for our business getting that middle layer write means universal patient access to high-speed internet and high-quality technology. the systems that are more uniform or workable in their

applications or approaches, giving the middle layer leads us on the position we can compete on the things they want to compete and thought to give the preferred contract. >> the fundamental service industry got it right for you respecting that your money is your money. it was the network technology that enabled them in the form of credit card, visa, mastercard. this industry has some respect that the data belongs to the consumer or the patient and until it does it doesn't matter how much technology is out there it is never going to flow freely or be controlled by the consumer. >> in our case we are business

to business. it is to our advantage we figured all that stuff out and any improvements have come through help us but don't change the equation because we will deliver the care. >> you just need standards to govern. it is a pretty exciting start where you can go and see how has ththe patients then treated ande spent some time altair.

>> it is another parallel. imagine if you bought a car and with it came the ability to only drive on certain road. that is how it is working with us and i hope care space right now. that is where you have the tools and vehicles and infrastructure so you can operate on the infrastructure so long as you buy a car you can drive on any highway. >> while we are waiting for that one payment system we will open up for questions. >> [inaudible] one of the things the industry has done really well is legislating to help make sure that happens.

the data architectural systems to my knowledge. i am surprised at how strict it actually is. people have been victimized when the data gets out there it is disastrous. as iso they starts from having well-trained professionals coming from healthcare they will come from some internet security background.

more importantly the internal process that you do day-to-day it isn't really known what they are doing and just being completely unaware of this type of cyber attacks are out there. so having a really good chief information security officer and company. >> you just touched upon in regulation and i want to go a little further on it because there are certain states. how do you manage that benchmark

in the patient ratio. how do you manage those benchmarks and advocacy groups? we are not replacing that there is an important point. it's added to the ratios that we are currently working with, so the responsibility rests with the hospital. they are typically bedside ratios. then we are complementary to what they choose to employ.

>> have you seen any characteristics that make for good providers? i think what we have come to understand is that a good dr. will make the technology go away and disappear. we can train the doctor on what it takes and the difference through telemedicine. we have those that cannot quite make that. but if we are starting with a c-

student that is a big bridge to cross. but if we got them to teach a little bit that is an easier challenge, so from our perspective a good doctor starts with finding a good doctor, and that will translate well into the telemedicine space. >> i would add from our perspective, a good doctor in terms of the employment equation and the model is our positions that are working alternate from time to time between being the alpha and the situation and the consultant. we need to not only how your good doctor's folks that understand and are comfortable being able to facilitate with

flipping between those roles is important to get the patient outcomes that we need. the sensitivity to take care of the population. >> that is something we will work on everyday becaus every de serving the medicaid population in the business, we are dealing with a whole host of cultures. in texas we have the rio grande a situation where a lot of them

are mexican-americans and may not go english. we deal with a lot of thought and the communities. it's towards the population that can use it to its fullest extent as a social benefit. can they fit the needs of the specific community and then

create the replacement? it's keeping the price as low as possible and we need to make sure the servic surface is not y more convenient but cheaper and more affordable and sometimes it works against us because in a price to value connection people make i don't want discounted sushi. saving an extra 20, 30, $40 is meaningful so keeping the prices cheaper than it would cost to go to a clinic does a lot of good for a lot of people out there. >> one of the things we find ourselves doing the is having

the providers speaking on very serious issues with some of the family members making very difficult decisions about end-of-life type of decisions and counseling them on how to make the decisions. it's being able to spend time in a non- friendly way to walk people through what choices are and what people represent.

it can be delivered if i have h., and i need to get around till the psychiatry i cannot call and wait a few days. so it is the same as the end-of-life issues. it is the critical care moment that comes up and you cannot anticipate them. so that was shared as an important piece of it. when you think of healthcare, you cannot necessarily measure the health care its self but you can measure the intrinsic value of the patient outcomes and the well-being is based on a wad of the platform. any other question? >> i work primarily with seniors and their families and they are seen on the tail end of the

adoption curve when it comes to technology yet i see seniors that have mobility issues, transportation issues and comorbidities as potentially ideal clients. i see firsthand very exactly mental health access so i wonder how do you help them overcome to utilize your services? >> that is a good question that goes back to the patient engagement side of things. we work with skilled nursing

facilities and it will be promoting tele- psychiatry to the elderly population that they are serving. that is a different proposition if i'm knocking on somebody's door and it takes them 30 seconds to even come to the door because they don't know me. they are used to certain things in terms of where they can get care and how, who tells them what good care is. so we are trying to plug into the existing frameworks and whatever they may be and have those folks promote to the senior population. >> to build on that, about 15% of the users are actually over 60 is a pag 60 years of age. my mother is 73 and lives in a small town of kentucky.

any time you are developing its just making sure it is designed in a way that is simple to use. when you get a product that it solves itself. >> i work for a children's therapy clinic for children with

special needs. we have been dabbling with tele- health but we are not sure if it is going to suit the client population so i wondered if you had any comment on this particular and if you've noticed any success in the industry. thank you. >> we have little experience in that segment but haven't found supporting technology to help us address that effectively. >> you can make the case that you solved a problem that is much less complicated. you are getting patient does debate coach in the icu with no capacity to make their own decisions on technology like this.

your question in specific i don't want to be a broken record but it starts with helping the people on the ground, occupational therapists, physical therapists, understand what it is they think. that is the business model. to hear you out on what type will be most effective. you paint the constellation of what it is you need. you know you're population better than we do. >> there are plenty of companies that produce white label software to enable a providers such as you t two have meaningfl remote sessions and complicationconsultations. the technology that exists you

could do a better job with the technology in place. >> and this has been very remarkable access and it looks like the leading edge of the future movement such as health insurance being sold across state lines as well. the question that comes back is what do you do in terms of managing quality? this may be more for the samir. how does th is the quality piecd

or regulated and what do you do about that in terms of measuring the outcomes, how do you measure those? >> our answers are going to be different which will give the audience more to chew on. our providers joined the team that is joining the patient. it is part of the community mental health center. they have clinical protocols and certainly it is quality tested but as soon as it becomes it is getting it up to speed on the existing quality standards. when we are talking to the clinics it should be as if they were there in person.

they should hold them to the same standard. >> the first thing we do is ask every patient to rate us and get comments. that in and of itself you can provide feedback to a provider about that interaction. we have a 4.8 average rating. we have to appear review so it is double blinded and so our doctors worked together to

ensure quality across the board and we have a host of other match or exceed overall prescription rates retracting below in the average is on both of those. as other initiatives feel passionate about that is the practice being virtual and technology driven and the amount of data that we consume and analyze back for one of the single sources we measure for the providers to make sure that they are happy and productive. they love getting that data and seeing how they are attracting versus other doctors and practice. so getting that feedback that has been a huge lever driving the standards and outcomes.

>> i also want to suggest you may have a t-shirt and if you have any things to put in it before we close out. i know you are holding onto a good one. [laughter] >> keep calm and carry on. something like don't worry, healthcare is getting better. each of us are pushing hard to try to make things better and everyone in the room tried to make things better and it's all a better result for the health care system in the country.

>> this industry attracted me because of its relative level of maturity with technology adoption and it's attracting a ton of other great entrepreneurs to get a perspective on how to build services and experience that will help drive the cost for the system so there is so much excitement and innovation going on. we may not benefit, but our children will. >> if you haven't read the book by the nike founder, read it. he talks about his teachers

telling about the history of the oregon trail and exploration of the oregon trail and he adopted one of the slogans. if we were going to put it on a t-shirt it talks about the entrepreneurial adventure that we are on. [inaudible] [laughter] thank you very much, gentlemen. [applause]

that would increase the number

of ships. from the center for strategic and international studies, this is an hour and 15 minutes. >> we are going to get started. good morning, everyone.